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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1 ' 1601 E. HAZ 'd;t' EONAV1A., STOCKTON, CA SUN 29 1590 Telephone (209)466-6781 PERMIT EXPIRES 1 YEAR FROM i,DATE ISSUED t. �NVIICRION1MENTALHEALTa` (Complete in Triplicate) Application§d-Ihi� WFet7�>lii San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Address / City ize PM Job A r Owner's Name ddress Qr Phone ` Contractor Address I? License No. Phone TYPE OF WELL/PUMP: NEW WELL 0 _ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ; FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f__V INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS { ❑ In�dustrial ❑ Open Bottom � ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ; � 1,<-estic/Private El Gravel Pack�`� ❑ Tracy Type of Casing Specifications f'l Public ❑ Other ? ❑ Delta Depth of Grout Seal Type of Grout 1 _ I %I Irrigation - Approx. Depth 11 E stern Surface Seal Installed by Repair Work Done *--Type of Pump 5,4C H.P. ' State Work Done Well Destruction ❑ Well Diameter �� Sealing Material (top 50'1 — -1 Depth Filler Material (Below 50') F TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewei is fi I! available within 200 feet,I . rI p �-- Installation will serve: Residence_ Commercial_ Other 0 Number of living units: Number of bedrooms t-� " ; 3 ? 1 '' _�._ UJ-- Character of soil to a depth of 3 feet: "�" " — Water table depth SEPTIC TANK ❑ Type/Mfg ;'•�,] __ Capacity,) No. Compartments PKG. TREATMENT PLT. ❑ -� Method of Disposal Distance to nearest: Well Foundation I Property Line t / I i 4 LEACHING LINE ElNo. & Length of lines Total length/size FILTER BED ❑ Distance Foundation nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth I Size I� - Number SUMPS ❑ Distance to nearest: Well Foundation ° Property Line DISPOSAL PONDS ❑ k I hereby certify that I repared this application and that the work will be done in accordance with San Joaquin county ordinances, state an 4 rules and mgula" s of the n Joaquin Local Health Di1trict. Home owner licensed agent signature certifies the following: "I certify that in the performance of the work for which this permit is issued, Is fall not 1 employ an arson in such m ner as to be me subj t workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies a folio ing: "I ce that in t ma a the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion la of Cali rnia." The plican I f r all requ' m eta drawing on id Signe Title: Dater) �FOEPARTIVI NT USE ONLY r ��a Application Accepted by Date Area Pit or Grout inspection by Date Final Inspection by Date 3 -111 ii Additional Comments: I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy i�,835-6385 Applicant - Return all copies to: Environmental Heakth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEAMOUNT DUE' AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. { INFO CASH � II ..EH 13-241REV.4ik 5f 1 EH 14-2e Ii